Also know as Stuttering
Most common causes:
• Cerebral palsy
• Developmental stuttering or cluttering
• Language impairment
• Traumatic brain injury (TBI)

You may observe:
• Difficulty expressing basic needs and providing routine information
• Embarrassment, anger, anxiety, fear, and/or frustration from awareness of speech disfluencies
• Avoidance of situations, words, and sounds that are likely to cause disfluencies
• Avoidance of communication with certain individuals (such as a teacher or principal)
• Social and/or emotional isolation (which can result from or worsen withdrawal, reduced self-esteem, and/or depression)

BEHAVIORS THAT SHOULD TRIGGER AN SLP REFERRAL

Preschool-age child
• frequently reacts to repetitions and/or prolongations; for example, child becomes intolerant of occasions when he repeats a syllable a few times, calls attention to disfluency, and disrupts conversation (e.g., “I bro-bro-bro–Mommy, I can’t say that …”)
• parent/caregiver reacts to child’s repetitions and/or prolongations; child notices adult behavior and becomes concerned also
• observable signs of muscle tension during disfluencies
• exhibits observable escape behaviors (e.g., eye blinks, head nods, and “ums”)
• demonstrates awareness of disfluencies and feelings of frustration
• caregivers and/or parents exhibit concern that the child’s disfluencies are a problem

School-age child
• child, parents, and/or teachers exhibit concern about disfluencies
• obvious sound repetitions, prolongations
• muscle tension may cause child to shut off sound or voice momentarily during speech
• use of escape behaviors, such as looking away from speaker, to end episode
• avoidance behaviors emerge from feared words, situations and/or people where child anticipates being disfluent

Teenagers
• more severe disfluencies than described for school-age children (e.g., muscle tension with disruption of speech is often more severe and includes lip, tongue, and jaw tremors
• complex, habitualized patterns of avoidance (e.g., avoiding certain words that are more likely to produce disfluency) and escape behaviors (e.g., taps fingers on desk while speaking in attempt to avoid or end a disfluency) from repeated suppression of disfluencies
• increased fear and embarrassment that negatively affect self-concept (such as feeling that teacher thinks less of them, perhaps that they are less intelligent, due to disfluencies)
1Behaviors are clustered to indicate different levels of function and/or patterns commonly associated with different medical conditions or etiologies.

Related Terms:
Apraxia of speech, avoidance behavior, block, circumlocution, cluttering, developmental disfluency, dysarthria, eye contact, perseveration, prolongation, prosody, repetition, revision, slurred speech, sound distortion, sound omission, sound substitution, stammer

Most common causes:
• Autism
• Developmental delay
• Fetal alcohol syndrome
• Hearing loss

You may observe:
• Difficulty communicating basic needs (such as safety, pain, toileting, or hunger/thirst)
• Difficulty exchanging routine information (such as following directions or stating preferences)
• Difficulty functioning at level of independence expected for age (such as doing homework or household chores)
• Difficulty engaging in social interactions; risk for frustration or depression
• Difficulty meeting educational potential; loss of previous academic status
• Risk for personal injury due to communication limitations

BEHAVIORS THAT SHOULD TRIGGER AND SLP REFERRAL

RECEPTIVE LANGUAGE

By 2 years does not
• identify basic body parts
• understand simple commands like “give me” without gestures
• demonstrate action words (e.g., eat)

By 4 years does not
• understand comparisons
• make inferences

By 5 years does not
• understand complex directions
• understand concepts

School-age receptive language/learning
• difficulty understanding teacher’s instructions and class discussion; following directions/rules; comprehending conversation and/or movies; differentiating between sound and/or words and relating them to meaningful information
• difficulty with reading comprehension across subjects, particularly abstract material with complex grammatical structure, and technical vocabulary; differentiating between letters and/or words and learning the meaning of visual symbols
• difficulty in mathematical reasoning, learning numbers, and/or understanding numeric concepts and applications

Receptive language with recent decline in function
• exhibits sudden or significant gradual loss in ability to understand and/or respond to oral and/or written language
• exhibits fluctuations in ability to understand and/or respond to language (e.g., 3-year-old may respond to simple questions most of the time but have difficulty during recurring periods of days or weeks)
1Behaviors are clustered to indicate different levels of function and/or patterns commonly associated with different medical conditions or etiologies.

EXPRESSIVE LANGUAGE

By 2 years does not
• refer to self by name
• speak using 1–2 words at a time (e.g., “Dan hat”)
• use new words frequently; use at least 50 words

By 2½ years does not
• respond to hello and/or bye-bye consistently
• use short sentences (e.g., “Daddy go bye-bye”)
• name one color

By 3 years does not
• relate experiences verbally
• state own first and last name
• count to 3

By 4 years does not
• use short but grammatically correct sentences
• speak abstractly

By 5 years does not
• use complex sentences
• explain how to do something
• respond to “why” questions with a reason

School-age expressive language/learning
• difficulty learning appropriate word production and usage, and relationships of words, phrases, and sentences to express needs/desires; may result in frustration or embarrassment
• difficulty with expression affects interactions with peers
• communication intent often misunderstood
• odd/unusual language

– echolalia
– delayed or no response to others
– difficulty using pronouns appropriately
– sounds that are not true words
– immature or inappropriate language in comparison to peers
– one-sided conversations with others
– social isolation/severely reduced interest in communication

• difficulty in oral expression, including appropriate use of words, grammar, and underlying meaning of words to report information, express ideas, and draw conclusions and/or inferences; usually affects social communication, particularly the ability to effectively explain situations and experiences
• difficulty in written expression, including appropriate letter formation, word selection, spelling, grammar, and use of sentences and paragraphs to complete schoolwork
• difficulty in basic reading skills, including the ability to decode letters and words to attain information, draw inferences and conclusions, and make associations, in the school, home, and community
• difficulty with mathematical calculations, including reasoning to perform mathematical applications and equations, money management, measurement and projections, and/or calculations of time

Expressive language with recent decline in function
• sudden loss or significant gradual loss in production of spoken and/or written language

Related Terms:
Agnosia, aphasia, apraxia of speech, babbling, developmental delay, echolalia, emotional lability, hemiparesis, hemiplegia, jargon, learning disabilities, paraphasia, perseveration, pragmatics, vocalization

Most common causes:
• Cerebral palsy
• Craniofacial disorders (e.g., cleft lip/palate)
• Functional articulation and/or phonological disorders

You may observe:
• Difficulty expressing needs or routine information intelligibly
• Difficulty communicating intelligibly to function at level of independence expected for age
• Difficulty expressing feelings intelligibly; may be at risk for frustration or depression
• Difficulty engaging successfully in social and/or classroom situations that require intelligible speech
• Difficulty achieving adequate intelligible speech to reach educational potential
• Risk for personal injury because of difficulty communicating intelligibly about a dangerous situation or calling for help

BEHAVIORS THAT SHOULD TRIGGER AN SLP REFERRAL

By age 3 years cannot
• be understood by family and/or caregivers
• correctly produce vowels and sounds such as p, b, m, and w in words
• repeat when not understood without becoming frustrated

By age 4 years cannot
• be understood by individuals with whom they do not associate regularly
• be understood by family and/or caregivers
• correctly produce t, d, k, g, and f sounds
• be asked to repeat without becoming frustrated

By age 5 years cannot
• be understood in all situations by most listeners
• correctly produce most speech sounds
• be asked to repeat without exhibiting frustration

Disturbance in neuromuscular control
• speech is usually slurred, with difficulty controlling respiration for speech; exhibits abnormal loudness, rhythm, or vocal quality
• child has difficulty learning sounds to form words; may sound nasal, strangled, and/or breathy
• child becomes frustrated and/or avoids speech because of problems forming sounds or difficulty being understood

Disturbance in programming, positioning, and sequencing of muscular movements
• sound errors are prevalent but variable (e.g., “dog” could be produced as “dog,” “tog,” “gog,” or “god” by same child)
• child varies from rarely being able to produce sounds to ongoing speech that is rarely understood, or speech that is usually understood with frequent sound errors
• child is unaware of sound variations or exhibits varying degrees of frustration and/or anxiety regarding inability to “control speech”

Disturbance in performing voluntary movements with mouth and vocal mechanism
• cannot produce movements for sound production, or sounds are produced without voice (whispered speech)
• varies from inability to produce any words to extreme difficulty being understood
• exhibits frustration and/or avoidance of speech due to difficulties

Hearing loss
• has prosodic disturbances in intonation, duration, and rhythm in addition to sound errors
• has difficulty differentiating between sounds; problems detecting and correcting sound errors
• produces no meaningful words, or sounds are understood only by family
• speaks loudly in high-pitched voice with frequent distortion, omission, and substitution of sounds

Autism, emotional disturbance, and/or intellectual disability
• intonation and/or rhythm of connected speech may sound abnormal
• volume may be consistently or intermittently too loud or too soft

Deviation in structure of speech mechanism
• has difficulty producing specific sounds and intelligible speech
• exhibits frustration and/or avoidance of speech
• has excessive nasality in speech
• has problems speaking clearly due to tracheostomy/ventilator dependence

Sudden decrease in speech intelligibility
• speech ranges from slurred but generally intelligible to total absence of speech or totally unintelligible speech
• awareness of sound errors ranges from extremely aware to totally unaware

Related Terms:
Apraxia of speech, articulation, developmental delay, dysarthria, intonation, intubation, nasality, phonological disorder, prosody, resonance, slurred speech, sound distortion, sound omission, sound substitution, speech, speech intelligibility, structural deviation, tracheostomy, velopharyngeal incompetence

Most common causes:
• Executive function disorder
• Brain tumors
• Stroke
• Traumatic brain injury (TBI)

You may observe:
• Reduced awareness and ability to initiate and effectively communicate needs
• Reduced awareness of impairment and its degree (i.e., loss of ability to assess one’s own communication effectiveness)
• Reduced memory, judgment, and ability to initiate and effectively exchange routine information
• Difficulty performing personal lifestyle management activities effectively (e.g., pay bills)
• Reduced ability to anticipate potential consequences, with reasonable judgment and problem solving
• Reduced social communication skills and/or ability to manage emotions, often causing loss of relationships
• Disruption of ability to fulfill educational or vocational roles, including potential loss of employment
• Risk for injury because of inability to communicate in an emergency and/or anticipate the consequences of own actions

BEHAVIORS THAT SHOULD TRIGGER AN SLP REFERRAL

Difficulty functioning independently due to
• lack of or atypical responsiveness to all external stimuli:

– may open eyes, suck, and/or yawn

• inability to attend to others
• extremely impaired attention and memory with impulsivity
• severely limited communication:

– lack of purposeful speech
– difficulty responding to and/or saying name
– difficulty expressing basic needs to others using simple words and/or gestures (such as yes or no, or head nod)
– difficulty saying greetings (such as “hi” and “bye”)

• difficulty remembering spouse/caregiver’s name
• difficulty counting to 10
• agitation when needs are not met
• limited eye contact
• limited social behaviors (such as expressions of courtesy and common facial expressions)
• moderately limited communication:

– difficulty paying attention while speaking (i.e., does not complete sentences or loses train of thought)
– difficulty responding appropriately to message of other individual (i.e., delayed, perseverative, or off-topic responses, including inappropriate words)
– limited ability to provide biographical information
– difficulty understanding abstract information; very concrete responses

• problems anticipating consequences of own actions
• poor organization, with limited problem solving and judgment

Difficulty managing home or maintaining job or business due to problems
• making, following, and modifying plans as needed
• planning and completing necessary daily activities
• following directions
• comprehending or applying abstract written information
• analyzing personal and/or business problems, identifying and applying solutions
• assessing own strengths and weaknesses, developing effective plans to improve weaknesses
• managing multiple responsibilities simultaneously
• managing emotions (especially anxiety, frustration, or anger) related to performance difficulties
• making, following, and modifying plans as needed
• understanding and managing personal legal or financial matters (i.e., taxes, buying or refinancing a home, etc.)
• effectively communicating with colleagues and/or customers, especially initiating effective responses, interpreting combined verbal and nonverbal responses during conversations to determine strategic communication action, and modifying response when feedback indicates it has not been successful

Related Terms:
Abstract information, anosognosia, attention, cognitive rehabilitation, community reentry, concrete information, emotional lability, executive functioning, external stimuli, eye contact, impulsivity, memory, perseveration, pragmatics, redundant responses, social communication, tangential responses, verbose responses